Revising and Retraining for Greater Survival Rates

Six months after the American Heart Association formally adopted new guidelines for emergency cardiovascular care (ECC), national organizations are releasing newly revised training materials to help ensure that the practice of first aid, including cardiopulmonary resuscitation, conforms to the latest science available.

Under the 2010 "Guidelines for Emergency Cardiac Care," chest compressions, not airway concerns, have taken priority. The changes re-order the treatment steps from A-B-C to C-A-B. First aiders have been administering the former sequence for 40 years; the changes were precipitated by a better understanding of which actions actually increase survival rates.

When the new ECC techniques were announced, Dr. Ralph Sacco, AHA president, said, "The research behind the guidelines is telling us that more people need to do CPR to treat victims of sudden cardiac arrest, and that the quality of CPR matters, whether it's given by a professional or non-professional rescuer."

The National Safety Council, the American Red Cross, the Health & Safety Institute, and their affiliates are adopting the new guidelines. The sidebar on page XX offers a summary of 2010 first aid changes.

Revising Training Materials
Accepting the guidelines is relatively easy; the revision of training materials requires a greater investment of time and money. Dr. Michael Sayre, an AHA spokesman and emergency medicine physician at Ohio State University Medical Center, explained that AHA's comprehensive process actually started about two years ago.

"Because the schedule for reviewing scientific studies was well defined, the product managers could predict some of the changes that would be coming up, but not all of them," he said. "As various groups writing articles with the new science proceeded, the product managers had the chance to read the documents while still in press and could ensure that the changes would be incorporated."

AHA employs part-time specialists and professional writers to ensure training materials accurately reflect the scientific guidelines, Sayre added. "Each of these products is on a fairly rigorous, tight schedule. Many require video be shot and scripts approved. Someone with scientific knowledge has to make sure that the techniques being shown correctly demonstrate the skills we want people to do," he stressed.

Barbara Caracci, the National Safety Council's director of Program Development and Training, First Aid Programs, explained that a 12-minute instructor video that traditionally takes three months to produce has been fast-tracked to two weeks. NSC has targeted 10 classroom and four online programs for revision. Interim training materials were available in February, and many course materials were finalized by the start of the second quarter of 2011.

Retraining the First Aid Force
New guidelines also mean new training for companies and their employees. While some businesses provide first aid training because it is "the right thing to do," many are compelled by 29 CFR 1910.151(a) and (b). This OSHA standard requires employers to ensure that medical personnel are available to provide advice and consultation on plant health matters and "In the absence of an infirmary, clinic, or hospital in near proximity to the workplace . . . a person or persons shall be adequately trained to render first aid."

"With the Near Proximity Rule, if you are not in near proximity to definitive health care, you have to have trained responders and a first aid kit," explained Caracci, who has worked for the safety council for 30 years. "Near proximity" has been interpreted to mean within four minutes, she said, adding that "most businesses are not in near proximity to definitive health care."

In addition to these regulations, OSHA recommends companies keep their first aid training up to date with current techniques and knowledge. From any vantage point, that means businesses will need to retrain their first aid force, but not necessarily at greater cost. For example, if employees certified under 2005 guidelines have not yet reached their two-year renewal date, employers can wait until that deadline to advance to 2010 training. The general consensus is that training based on the 2005 guidelines is still valuable.

When training must be renewed, companies have several options. They can choose online, off site or on site, and train-the-trainer classes, or a combination of these.

Online training, which is not subject to regulation, can be offered by any company or organization. For example, one "free" online CPR course provides basic information and a short test. Those who pass are invited to order a downloadable certificate or wallet cards for $24.95. The process can take less than 10 minutes. The value of such training is debatable.

"None of us wants the equivalent of the puppy mill," Caracci said, adding that the National Safety Council is a competitor of AHA and the Red Cross, but the three try to work cooperatively.

"I sit on the committee that writes first aid guidelines. I've worked with these others at my same level for years," she explained. "We want people proficient in first aid. When we get these places where you pay 20 bucks and you get a card, that does a disservice to all of us who are working to get people trained properly."

Ensuring Effective Techniques
The council offers a blended approach, requiring those who want a completion card (which is different from a certificate) to take the online course and follow up with hands-on skills training with a local or chapter-based instructor. That training can take up to three hours.

AHA's online training uses experts in educational techniques and methods to ensure the association presents the information in a way that helps the person learning actually remember what to do in an emergency. "For certain things, like doing chest compressions, it's really important for students to practice skills, to do muscle memory," said Sayre. "With chest compression, you can learn something by reading about it. To do a good job, you need to practice. Frequency of the practice matters as well, but the practice doesn't have to take very long," he said. Nursing students practice as little as five minutes a month, he added.

Research supports using both training methods in tandem. The 2003 study "Classroom Versus Computer-based CPR Training: A Comparison of the Effectiveness of Two Instructional Methods," by Robb S. Rehberg, Ph.D., found students can learn information and sequences equally well online and in the classroom, However, the study's authors noted that critical skills require direct contact with an instructor. As an educator, Caracci agrees. In the classroom, instructors can correct errors immediately and reinforce material. OSHA also recommends that training programs include instructor observation of acquired skills and written performance assessments.

The measure of CPR effectiveness relates to the percentage of people who walk out of the hospital following emergency cardiovascular care. Experts often cite Seattle, Wash., as a model for building success: It has widespread CPR training and a short time to EMS response and defibrillation, resulting in a 30 percent survival rate for witnessed ventricular fibrillation cardiac arrest, according to AHA. In contrast, the survival rate in New York City averages 1 to 2 percent.

Caracci noted that casinos achieve great save rates because they hire professional rescuers, require their security force to take training, install automated external defibrillators, and use security cameras to watch their customers.

Several studies have documented that AED-trained and -equipped responders saved twice as many lives as those who used only CPR, Sayre said. With the 2010 guidelines, CPR- and AED-trained employees should be empowered to be more than bystanders.

One warning: Reading up on the new guidelines and then using them in an emergency is not a good idea. "You need to act as you were trained to act," Caracci said, explaining that Good Samaritan protection is in force only when people use the skills they were trained to use -- even if that means calling 911, checking the victim's airway, administering mouth-to-mouth resuscitation, and then performing chest compressions.

"Anything you do will help," she said. According to an AHA Fact Sheet, effective bystander CPR, provided immediately after sudden cardiac arrest, can double or triple a victim's chance of survival.

This article originally appeared in the April 2011 issue of Occupational Health & Safety.

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